Theory and ( Seriously) Confronting Health Inequalities

I have always regarded ‘theory’ as an inescapable component of writing about the world we inhabit. To say how the world is, in however modest a fashion, is after all to sign up to a family of ontological, epistemological and moral premises: that is to say, to sign up to a degree of commitment to what exists, what we know what about it and how it ought to be. The third of these might occasion some surprise, but it shouldn’t. Not to challenge the status quo – leaving everything as it is – is every bit as morally revealing as challenging it. Of course those who presume moral neutrality when campaigning for novel interventions ‘against’ disease or impairment tend to be more relaxed about their tacit positioning than those who campaign ‘against’ health inequalities; but there you are. So for me, we are stuck with theory in all its facets, like it or not, confess it or not.

I have taken for my ‘sermon’ in this blog a trio of incursions, two of them especially topical. It suits to take them in order of publication. American anthropologist Arthur Kleinman comes first. Global health, he asserts, ‘is more a bunch of problems than a discipline.’ As such, he continues, ‘it lacks theories that can generalize findings – through an iterative process of knowledge construction, empirical testing, critique, new generalization, and so on – into durable intellectual frameworks that can be applied not only to distinctive health problems, but to different contexts and future scenarios.’ Drawing on his Harvard teaching experience, he goes on to delineate four pertinent social theories.

The first derives from Merton. In a nutshell, its focus is on the unintended consequences of purposive – social – action. All social interventions have unintended consequences, some of which might, with reflection, be foreseen and prevented. This indicates a need for timely anticipatory evaluation, the equivalent of medicine’s ‘first, do no harm.’ But this is serious stuff: consider, for example, the sexual revolution that resulted from China’s one child per family population control policy.

Second, Berger and Luckmann’s text on the social construction of reality is cited. This asserts that the ‘real world’ is not only material but is also ‘made over into socially and culturally legitimated ideas, practices and things’. Thus, for example, mental illness is widely and transnationally stigmatized, while abortion is highly contentious in the USA but not in Japan. One challenge for a global public health is the existence of ‘local moral contexts’ that influence the perceptions, values and behaviour of their populations; moreover these can be neighbourhood- specific.

Kleinman’s third theory is that of social suffering. This, it is claimed, has four implications for global health: (a) socioeconomic and sociopolitical forces can on occasions cause disease, as with the structural violence of deep poverty that creates the conditions for TB; (b) social institutions, including health care bureaucracies, can actually increase suffering (e.g. clinical iatrogenesis); (c) the term social suffering conveys the idea that suffering is not specific to individuals but can embrace significant others, even whole communities; and (d) the phrase also collapses the distinction between health versus social problems, allowing for an acknowledgement that they can be intimately related.

Fourth, Foucault’s notion of ‘biopower’, which highlights the way in which political governance increasingly operates by controlling bodies and populations – with health consequences – is noted. By way of illustration Kleinman records how the UN ‘system’, plus its agencies as well as individual nation states, use biopower so that global health programmes can come to serve ulterior purposes

The thrust of Kleinman’s thesis is that theories like these (and more – he mentions Weber in passing) can help students in medicine as well as public health develop intellectual frameworks that lead to deeper critical reflection. Social theory, in short, can and should be ‘another instrument of improving health and reforming health care’.

The second of the three articles was authored by Michael Marmot. Committed to ‘evidence-based politics’, he digresses to reflect on the role of theory. His starting point, predictably, is the ‘social gradient in health’. His focus is on ‘the causes of causes’. He confesses to having stopped using the term ‘social class’ because ‘it has baggage and multitple meanings’, preferring ‘the neutral-sounding term, socioeconomic position’. He addresses critiques of positivism, but equates ‘so-called’ critical theory with forms of postmodern social constructivism that culminate in Trump and fake news.

Marmot makes three additional points. First, he says he finds Weber’s account of social stratification, emphasizing that a person’s ‘status’ is a characteristic of society, appealing. Second, he goes on to insist that it is important to draw attention to the ‘structural drivers of health inequalities: inequities in power, money and resources’. And third, he presents a quandry: which is ‘more important’, relative or absolute poverty (a query motivated by his steadfast commitment to the social gradient)? His answer: ‘it is not so much what you have that is important for health, but what you can do with what you have.’ For sociologists this boils down to reference group theory, which antedates Marmot’s ‘status syndrome’. Marmot approves of Sen’s work on ‘capabilities’, which puts the accent on the freedom to live a life one has reason to value.

‘If theory is a way of organizing one’s thoughts, an explanation of how the world works, and thus an aid to understanding and a guide to action, then the charge of being atheoretical is one to take seriously’ (importantly, Marmot adds, ‘if not a theory, then at least a model’).

Much of the rest of Marmot’s article is devoted to a strong defence of the notion that social conditions cause ill health, rather than ill-health causing social conditions. At root, he suggests, this division of opinion is one of ideology. He then addresses a criticism of his WHO report by Navarro:

‘Vicente Navarro praised the report. He then went on to chide us for not going far enough. His view was that we know who the killers are. My response was that we had reviewed the evidence on social determinants of health. I was perfectly content if others wanted to say that health inequalities resulted from a toxic combination of poor quality social programmes and poor governance – and gave the evidence to support those contentions.’

And he goes on:

‘a related challenge was: ‘isn’t the problem really capitalism’. My response to this, too, is likely to disappoint. I point out that the countries with the best health, longest life expectancy, are Japan, Iceland, Sweden, and now Hong Kong – all capitalist countries. Evidence should suggest that it is not so much capitalism, per se, that is the problem but how particular capitalist societies are operated.’

The final paper is by Richard Horton and is intriguingly entitled ‘Medicine and Marx’. Did Marx’s theory die with the implosion of the Soviet bloc? Horton cites Engels, Redman (‘medical-industrial complex’) and Waitzkin in asking whether improvements in health care systems can occur without fundamental changes in the social order. He concludes his brief discussion with these words:

‘I think Marx matters to medicine for three reasons. First, Marx offers a critique of society, a method of analysis, that enables explication of disquieting trends in modern medicine and public health – privatized health economies, the power of conservative professional elites, the growth of techo-optimism, philanthrocapitalism, the importance of political determinants of health, global health’s neoimperialist tendencies, product-driven definitions of disease, and the exclusion of stigmatized communities from our societies. These aspects of 21st century health care are all the better investigated and interpreted through a Marxist lens. Second, Marxism defends a set of values. The free self-determination of the individual, an equitable society, the end of exploitation, deepening possibilities for public participation in shaping collective choices, refusing to accept the fixity of human nature and believing in our capacity to change, and keeping a sense of the interdependence and indivisibility of our common humanity. Finally, Marxism is a call to engage, an invitation to join the struggle to protect the values we share. You don’t have to be a Marxist to appreciate Marx. As the centenary of his birth approaches, we might agree that medicine has a great deal to learn from Marx.’

Three very different papers with differing foci as well as conclusions. I will try not pull too many punches.

I entirely agree with Kleinman, not only that theory is the way to frame/make sense of the social world we collectively inhabit, but that social or sociological (ok, he’s an anthropologist, so anthropological too) theory is a critical resource. It is a critical resource both for education and for effective interventions. I would commend all four of the sources he cites, but would add others, most notably Marx, critical theory and critical realism.

I am more critical of Marmot’s contribution. Whilst I applaud his career-long epidemiological contribution to our understanding of health inequalities, plus his commitment to and advocacy of change, I have several qualifications: (a) I don’t think he grasps the significance of ‘the social’, that is, as something other than, and over, the aggregate of individuals comprising a given population; (b) his dichotomous portrayal of positivism versus postmodern social constructivism, and his conflation of the latter with critical theory, is either ill-informed or disingenuous; (c) he ends up being very selective in the theorists he takes on board and assesses; (d) he is so concerned to be an influential ‘insider’ that he ends up compromising his theoretical ambitions (in as far as he understands them); (e) it falls to ‘outsiders’ (like Navarro) to draw on a wider range of theories to interrogate the role of capitalism, its contradictions, and class antagonisms in the production and reproduction of health inequalities; and (f) his insider logic renders him unreflexive about both epidemiology’s explanatory limitations and his failure to properly theorize the contributions of macro-social factors to explaining health inequalities.

This may seem a harsh judgement and a paragraph of elaboration is in order. I see epidemiology as an essentially positivistic sets of tools oriented to prediction in the service of public health. It can of course also nurture explanation; but it does so circuitously, by affording cues as to the existence of the mechanisms that issue in phenomena like health inequalities. These mechanisms are on a spectrum from the biological through the psychological to the social. Marmot, as an epidemiologist, occupies more common epistemological ground with quantitative-leaning biologists and psychologists than with sociologists (and anthropologists) who embrace qualitative and ethnographic as well as quantitative research. Marmot does not ‘get’ qualitative and ethnographic social science.

Horton shows all the audacity that Marmot shuns. His brief, punchy call to theoretical action acknowledges that theorists like Marx (no Michael, not Groucho) ask questions that still resonate – and powerfully – in the 21st These questions open the door to a genuinely macro-sociological input into an interdisciplinary explanation of health inequalities. I have myself published in this area for twenty years without ever being cited – even critically – by Marmot (though to be fair, I have only exceptionally been cited by those sociologists-cum-epidemiologists who worked with him). To my mind, it is bad sociology to side-step matters that the likes of Navarro, Horton too, are willing to confront.

Kleinman is right to point out the multiple theoretical resources available to those who want to explain and (note the ‘is-to-ought’ here) effectively reduce health inequalities. Marmot is, I think, unaware and unopen to those of these resources that threaten his insider status. I understand his politics, but in its pursuit he restricts the explanatory potential of ‘his’ understanding of epidemiology. There is a vital role for outsiders, for critical, public, foresight and action sociologies in relation to health inequalities, and for resisting insider co-optation and taming. In eschewing a real, reflexive engagement with the social, properly conceived, Marmot is leaving it to others, outsiders, to offer and pick up on those theories and forms of activism that speak to the social transformation necessary for equity and the ‘human flourishing’ to which he aspires. His long-term research output is inspiring; his global as well as national insider engagement no less so; but he needs to ask why things are getting worse and what needs to be done about it.